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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 Box Washington Avenue <br /> Asc6nsfn7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �� <br /> than 8 112 x 11 inches in size. C�• <br /> • See reverse side for instructions for completing this application State Sanitary�mitNumbgr <br /> 307 <br /> Personal information you provide may be used for secondary purposes Check if revision to previoul7u;s lication <br /> (Privacy Law,s. 15.04(i)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owr Name Property Location � <br /> n ' <br /> q N1JG /�f 1/4 _S= 1/a,S T N, R14 E(or 6�v <br /> Pr ope y Owner's Mailing Address X Lot Number _ Block Number <br /> yO <br /> City,Stat / Zip Code Phone Number ame or CSM Number <br /> IV TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms ❑ Village <br /> PC own OF Qi4A C.c1 <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s),;)_6 1(jj�� (_�\ <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B,if applicable) <br /> A) 1. ❑ New 2. Z[Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System ---_ _______ TankOnly__-_______ _ Existing System ___ ____ExistingSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 ffSeepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> gig p . _ �� Feet 577,4 Feet <br /> TANK Ca act <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /Poo 1 We r•w-cpcao ❑ ❑ ❑ ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print, Plumber's Signature:(No 5 mps) MP/MPRSWNO.: Business Phone Number: <br /> e:,2.;2 <br /> Plumber's Address(Street,City,Stapp,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sry Permit Fee (Includes Groundwater ate IssuedIssuing Agent Si n ure(No S ps) <br /> 514proved ❑ Surcharge Fee) <br /> Owner Given Initial -r�a <br /> Adverse Determination Will 7S-. <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />